| |
1936 Lee Rd Suite 290 Winter Park FL 32789-7229 | |
(407) 233-1864 | |
(407) 563-3264 |
Full Name | |
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Speciality | Psychologist |
Location | 1936 Lee Rd, Winter Park, Florida |
Authorized Official Name and Position | Gregory Van Dam (OWNER) |
Authorized Official Contact | 5612527336 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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1936 Lee Rd Suite 290 Winter Park FL 32789-7229 Ph: (407) 233-1864 | 1936 Lee Rd Suite 290 Winter Park FL 32789-7229 Ph: (407) 233-1864 |
NPI Number | 1689922528 |
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Provider Enumeration Date | 08/27/2012 |
Last Update Date | 04/12/2017 |
Medicare PECOS PAC ID | 5698923969 |
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Medicare Enrollment ID | O20120911000273 |
Identifier | Type | State | Issuer |
---|---|---|---|
1689922528 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
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103TC0700X | Psychologist - Clinical | PY 8572 (Florida) | Primary |
Provider Name | Gregory Alan Van Dam |
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Provider Type | Practitioner - Clinical Psychologist |
Provider Identifiers | NPI Number: 1942525548 PECOS PAC ID: 0840448114 Enrollment ID: I20120911000411 |
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